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Jay Jagannathan, Jason P. Sheehan and John A. Jane Jr.

an adenoma. Right: An SPGR MR image successfully revealing adenoma (arrow) in this patient with Cushing disease. Surgical Strategies in Patients With Negative MR Imaging Microscopic transsphenoidal surgery is the treatment of choice in patients with Cushing disease and is the first treatment in the majority of our patients. 13 , 24 Over time, our strategy has gradually evolved to include the endoscopic approach in patients with negative MR imaging to facilitate exposure and resection, although we have had success with the microscope as well

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John A. Jane Jr., Erin Kiehna, Spencer C. Payne, Stephen V. Early and Edward R. Laws Jr.

Inclusion criteria for the retrospective study included adult patients with craniopharyngiomas who underwent pure endoscopic transsphenoidal surgery. Between March 2005 and July 2009, 31 patients underwent transsphenoidal surgery for the treatment of a craniopharyngioma. Nineteen patients were excluded from the analysis. Nine patients were younger than 18 years of age, 6 adult patients underwent endoscopic-assisted microscopic resections, and 2 adults underwent purely microscopic procedures. Of the 14 adult patients who underwent pure endoscopic transsphenoidal resections

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Paul J. Schmitt and John A. Jane Jr.

intraventricular procedures. (Photo courtesy of Dr. Edward R. Laws Jr., reprinted from Prevedello DM, Doglietto F, Jane JA Jr, Jagannathan J, Han J, Laws ER Jr: History of endoscopic skull base surgery: its evolution and current reality. Historical vignette. J Neurosurg 107: 206–213, 2007.) Dandy continued to tinker with the design of his ventriculoscope in an effort to make it suitable for intracranial maneuvering; by 1932, he was again attempting an endoscopic choroid plexectomy. However, as recounted by Hsu et al., 8 in reviewing his 1945 text Surgery of the Brain

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Francesco Doglietto, Daniel M. Prevedello, John A. Jane Jr., Joseph Han and Edward R. Laws Jr.

Since its inception, one of the major issues in transsphenoidal surgery has been the adequate visualization of anatomical structures. As transsphenoidal surgery evolved, technical advancements improved the surgical view of the operative field and the orientation. The operating microscope replaced Cushing's headlight and Dott's lighted speculum retractor, and fluoroscopy provided intraoperative imaging. These advances led to the modern concept of micro-surgical transsphenoidal procedures in the early 1970s.

For the past 30 years the endoscope has been used for the treatment of diseases of the sinus and, more recently, in the surgical treatment of pituitary tumors. The collaboration between neurological and otorhinolaryngological surgeons has led to the development of novel surgical procedures for the treatment of various pathological conditions in the skull base.

In this paper the authors review the history of the endoscope—its technical development and its application—from the first endoscope described by Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery held in 2005 in Pittsburgh, Pennsylvania. Specifically, in this review the history of endoscopy and its application in endonasal neurosurgery are presented.

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Paolo Cappabianca, Theodore H. Schwartz, John A. Jane Jr., M.D. and Gabriel Zada

This issue of Neurosurgical Focus attempts to address recent advances in endoscopic endonasal skull base surgery. Although the concept of minimal invasiveness is not new to our discipline, improvements in endoscopic technology and instrumentation, as well as the gradual refinement of a variety of endonasal endoscopic approaches, have greatly facilitated our ability to safely treat a wide variety of skull base pathology that was not possible two decades ago. This speciality of neurosurgery requires precise anatomical knowledge, technical skills, and

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Kant Y. Lin, Richard S. Polin, Thomas Gampper and John A. Jane

Occipital plagiocephaly caused by lambdoid synostosis is rare. Positional flattening is more common and will most often respond to conservative measures. Surgical correction of a flat occiput is warranted if the deformity is profound. Skull molding devices may be effective for treating mild abnormalities but are ineffective in the more severe cases. An operative procedure is described that uses a microplate-reinforced median bar to provide a rigid scaffold to maintain the occipital correction. Seventy-three consecutive patients were evaluated over a 3-year period for occipital plagiocephaly. Of these individuals, only one had true lambdoid synostosis and six required surgery. There were no operative complications and cranial length was increased from 84 to 94% of age-matched controls after surgery. The need for operative intervention is rare; however, it should be based on the severity of the posterior deformity, especially when accompanied by compensatory frontal bossing, and not on the etiology of the flattening.

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Jay Jagannathan, Aaron S. Dumont, John A. Jane Jr. and Edward R. Laws Jr.

The diagnosis and management of pediatric sellar lesions is discussed in this paper. Craniopharyngiomas account for the majority of pediatric sellar masses, and pituitary adenomas are extremely uncommon during childhood. The diagnosis of sellar lesions involves a multidisciplinary effort, and detailed endocrinological, ophthalmological, and neurological testing is critical in the evaluation of a new sellar mass. The management of pituitary adenomas varies depending on the entity. For most tumors other than prolactinomas, transsphenoidal resection remains the mainstay of treatment. Less invasive methods, such as endoscopic transsphenoidal surgery and stereotactic radiosurgery, have shown promise as primary and adjuvant treatment modalities, respectively.

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John A. Jane Jr., Mary Lee Vance, C. J. Woodburn and Edward R. Laws Jr.

Object

Surgical and medical therapies successfully achieve biochemical remission in the majority of patients with secretory pituitary adenomas. Nevertheless, continued hypersecretion after first-line therapy occurs and requires adjunctive therapy to prevent morbidity and premature mortality. For patients in whom medical and surgical therapy have failed, gamma knife surgery (GKS) is performed with the goal of controlling tumor growth and excess growth hormone (GH) production. The authors report their experience with GKS in patients in whom surgical and medical therapies failed.

Methods

The neuroendocrine service at the University of Virginia has treated 220 patients with secretory adenomas. The authors evaluated the biochemical results in patients with acromegaly followed for greater than 18 months (64 patients) as well as those with Cushing disease (45 patients), Nelson syndrome (14 patients with adequate follow up [27 overall]), and prolactinomas (19 patients) followed for at least 12 months posttreatment. Biochemical remission occurred in 36% of patients with GH-secreting adenomas, 73% of those with Cushing disease, 14% of those with Nelson syndrome, and 11% of those harboring prolactinomas. Recurrence after biochemical remission was documented in four patients with Cushing disease. New hormonal deficits have occurred in 28% of patients with acromegaly, 31% with Cushing disease, 36% with Nelson syndrome, and 21% with prolactinomas. Minor visual deterioration developed in one patient with Cushing disease.

Conclusions

Gamma knife surgery offers an important treatment modality in patients with secretory adenomas refractory to surgical and medical interventions.

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Paul T. Boulos, Aaron S. Dumont, James W. Mandell and John A. Jane Sr.

Meningiomas are the most frequently occurring benign intracranial neoplasms. Compared with other intracranial neoplasms they grow slowly, and they are potentially amenable to a complete surgical cure. They cause neurological compromise by direct compression of adjacent neural structures. Orbital meningiomas are interesting because of their location. They can compress the optic nerve, the intraorbital contents, the contents of the superior orbital fissure, the cavernous sinus, and frontal and temporal lobes. Because of its proximity to eloquent neurological structures, this lesion often poses a formidable operative challenge. Recent advances in techniques such as preoperative embolization and new modifications to surgical approaches allow surgeons to achieve their surgery-related goals and ultimately optimum patient outcome. Preoperative embolization may be effective in reducing intraoperative blood loss and in improving intraoperative visualization of the tumor by reducing the amount of blood obscuring the field and allowing unhurried microdissection. Advances in surgical techniques allow the surgeon to gain unfettered exposure of the tumor while minimizing the manipulation of neural structures. Recent advances in technology—namely, frameless computer-assisted image guidance—assist the surgeon in the safe resection of these tumors. Image guidance is particularly useful when resecting the osseous portion of the tumor because the tissue does not shift with respect to the calibration frame. The authors discuss their experience and review the contemporary literature concerning meningiomas of the orbit and the care of patients harboring such lesions.

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John Persing, John A. Jane Jr. and John A. Jane Sr.

with nonsyndromic and syndromic craniosynostosis. 2 Strategies needed to be developed to correct these abnormalities completely and reduce residual deformities. The real problem, of course, all along, has been an inability to control for growth and adequately correct the abnormal basal skull. These problems are still vexing us today. Frustration with these techniques' inability to control such factors resulted in a belief that it is futile to attempt to obtain an absolutely normal-looking skull by surgical means early in infancy. Instead, we should delay surgery